This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Tuesday, 17 March 2009

Goodwill/ Working for Free/Documentation Hell

Why do nurses work long hours and then stay on unpaid?

To protect our patients from harm and thus protect the professional registration that we worked so hard for. That's why.

I have blogged about 8,12, and 14 hour shifts without breaks. I have also blogged about the fact that I may stay over at the end of these shifts another 1 or 2 hours unpaid.

I am no martyr and I do not want to work these kinds of hours any more than you do. I like to eat and sit on my ass and I like coffee. A lot.

If you have been reading this blog you know that we are short staffed and that I do not have another RN to fall back on if I need to eat, wee, my back hurts etc. My work load can be so insane that I often cannot stop and eat. I am insanely behind on interventions that could get someone hurt if they are not performed. I am hours behind and I cannot catch up due to interruptions. I can't go to the patients who are suffering from a lack of basic care until I catch that other stuff up. How the hell can you take a "break" in the middle of that? Even without taking a break and staying over unpaid to boot my nursing registration is at risk. If that goes I lose my ability to support my family.

Night shifts and weekend shifts are great because I can eat and sit for about 10- 30 minutes as long as all the patients are stable. There are less interruptions and I have a shot at getting everything done and getting out on time. I love those shifts.

But weekday day shifts? Forget it. They are just clusterfucks of total chaos. And they are not staffed any better than the weekend shifts.

At the end of the day, if a patient gets harmed the NMC will pull my license with pleasure. They don't care if we are short staffed or if I needed to stay over the end of my 8 hour shift by 3 unpaid hours to get finished. There are things that I can hand over to the oncoming nurse and things that I cannot hand over.

Documentation

The main thing that holds me over at the end of a shift is documentation. There is no time to do it during the shift (unless I ignore the patients).

The documentation that nurses are required to do is taken very seriously. I have known nurses who have lost their licenses over this.

Every move a nurse makes, everything she says, every conversation with every person she talks to about patient care, every test a patient has and every action of the doctor, social worker, physio, OT, dietitians etc has to be documented in at least 3 different places. God forbid a patient's change in condition or general assessment isn't documented in all these different places as well. They (Lawyers, NMC, management) also expect it all to be done as it is happening, not at the end of the day.

That is impossible. I would have to ignore the patients all day to pull this off as it is ordered and legally required to be accomplished.

I barely get time during my shift to actually take care of the patients and do anything but the most important forms. For example a life saving test may not get performed if I do not chase certain paperwork. Then it is my fault if said test does not get done.

Social services will not send carers to care for my elderly patient on discharge if I do not leave my other patients alone and fill in hundreds of forms and make about 10 phone calls. We no longer have a hospital social worker to sort this shit out and god knows what the clipboard carrying discharge nurse managers actually fucking do. God only knows.

Pharmacy will not send the drugs I need without many forms being filled in. Lab tests will not get done if forms are not sorted. Some of these forms I have to do an others have to be chased.

The other stuff gets left until the end of the day. So I stay over to do them. It is a legal requirement to complete this stuff regardless of the nurses' own personal situation.

Management says " if you nurses would organise your time better, then you will not have to stay over. No we will not pay you for staying late, just get yourself organised". But they won't give us any help or additional staff. It is my registration that gets pulled by the NMC if something doesn't get done. Not theirs. I could get called to testify in court if a patient sues and if my documentation was messy and half done the barristers will easily have me for lunch. No one cares how overwhelmed I was that day.

But getting it all done during my shift would mean ignoring the patients all day. Can't do that can I?

So other than documentation why do I have to stay over?

Self Preservation

Sometimes I hand over to the oncoming nurse and I realise that she is going to be in one hell of a mess.

At the end of my shift and the beginning of hers she has: two crashing patients that need one to one nursing support to implement medical interventions, 5 confused wanderers heading for the stairwell that cannot be reorientated, 10 patients who are demanding a commode and their nightimemeds, 8 families lining up demanding to speak to the nurse because "mum has the wrong colour nightdress on" and a drug round that usually takes 2 hours all happening and due RIGHT NOW.

You have to focus hard on the drug round and you have to do it as quick as possible so that you don't make mistakes or get written up because prescribed meds were given late. Fuck it up and /or get them out late and you are in deep. Drug rounds are complex and Medication errors kill and maim and the majority of them occur because nurses get interrupted on drug rounds.

She also has to have all of her patients assessed within the first hour of her shift. What happens if someone has no urine output and she doesn't catch it until 3 hours into her shift? The phone is ringing off the hook. Then there is everything else as well. So I stay on unpaid to special the critical patients so she can finish her drug round and deal with the other crap. She will do the same for me next time when I come on duty after her. It's not about being a caring martyr or loving my colleagues so much that I like to stay on to help them. It is about self preservation.

"Goodwill"? How about "totally fucking scared".

We have brittle diabetic nurses bottoming out all the time on duty because they cannot get a snack. When I was pregnant I swore that I would force myself to take a meal break and sit down. It didn't always happen. As hungry as I was I could not put my patients well being and THUS MY NURSING LICENSE at risk. I often worked very long shifts without breaks while heavily pregnant even when my preeclampsia started to kick off.

A nurse may be a brittle diabetic, or have asthma and back problems, or she may be pregnant. Management will not pay an additional RN to be on the ward so that these nurses can look after themselves for 30 minutes out of a 12 hour shift. And if anything happens to a patient, it will be the nurse herself who is punished and loses her ability to work as a nurse. At the very least, she will be the one that the patients and relatives complain about if something doesn't get done.

We have families to support. This goes out the window if I get struck off or I piss somebody off.

Patient AbandonmentAbandonment of patients by the RN responsible for their care is very illegal. They will strike me off for this and possibly prosecute me in a court of law. Once I take report I am responsible for my patients until I hand over their care to another RN. This is a good law. It stops me from walking off the ward because I am overwhelmed, crying, just been punched by a patient, etc. It is designed to protect the patients. It is a good law. If I leave those patients without handing over their care someone could get hurt and I am in deep shit. Managers love to take advantage of this to get free overtime out of us.

So what happens if there is no nurse coming on duty after me? I have to stay on and keep going until management decides to get/ pay another nurse to take over. I have unwillingly pulled many unplanned double shifts this way. Childminders sure know not to work for hospital nurses. Believe me. Once they find out you are a nurse they say no way. They know that when they look after nurses' kids that they end up keeping that child hours longer than they were asked too.

What happens if my child gets sick at school and there is no RN for me to hand over to so I can go and get him? I can't legally leave if there is not another nurse even if there are 10 care assistants. My husband has to ditch work in the middle of the day and get our child. He misses a lot of work due to the fact that he is married to a nurse. If I am one of two RN's for the whole ward and I really have to leave due to an emergency than I hand over to the other nurse. That leaves her legally responsible for 25 patients herself. She is now liable if anything happens, not management for not replacing me for the duration of the shift.

How's all that for rambling? Would love to go back and edit for grammar and spelling but it's just too long.

18 comments:

So true they come round each morning wanting a handover of what is happening with each patient. Then the bed manager comes and wants to know which patients are going home/ can be moved to a rehab hospital. The the physios and OT come to have a handover. Why all these people can't come round at the same time, so we don't have to repeat all the info which takes us away from the drug round again!

I'm an OT in an acute hospital and I hate having to interrupt nurses. I can completely understand when STAR asks why myself, the physio, discharge manager, bed manager, etc, can't all come for handover at the same time. Truth is we could if the nursing staff would accomodate us, but because we're as busy as the nurses (lack of staff is endemic in all NHS professions) it would have to happen consistently at the same time each day. I tried to set this up one of my wards last year. (I currently look after 3 wards)

All I asked was could we all (OT, ohysio, discharge management) come onto the ward for a quick handover each day. I was willing to be flexible about the time we agreed, so long as it could be some point between 8.30 and 9.30 as I regularly take patients on home visits in the mornings, and I need to leave for a HV by 10.00 if I'm going to guarantee I can have the patient back on the ward in time for lunch. Logical, yes?

The response from the nurses? No chance. Come and sit in on the nursing handover. Sounds like a good idea, but problems being A: the nursing handover can happen any time between 9.00 and 11.00 on that ward, they appear to do it whenever. B: nursing handover is not a good use of my very stretched time, as there's an awful lot of info I don't need - I don't see every patient unless they're all referred, so don't need to spend the 45 minutes it takes to be told that Mr Brown hasn't had a bowel motion yet today. and C: that 45 minutes is just the nursing handover for one ward team - the ward nursing is split into 2 teams, and they do both team handovers at the same time so it's physically impossible to attend both!

Am I asking too much to try and save time for all of us (nurses included, as it'd prevent them having to give handover 3 times) by arranging a dedicated 5 minutes each day? (All it'd take, as not too much OT/PT/discharge managemnt relevant stuff can happen since we last had handover yesterday)

Juli- actually now the OT and physio come to the ward together at the same time 9am,so we do know when to expect them,which is good and has made things easier,we also have a handover book where every patients name is written in each day so that we know who needs physio or OT input.

the discharge co-ordinator and the bed manager seem to turn up anytime between 8-11am. Would be great if they could come at 9am too, but i suspect that all wards are doing the therapy handover at 9am.

one of them being...that after an 8 hour shift..with no food or drink ..(and i was never a breakfast person so by 3pm I'd be very ready to faint...) I REALLY REALLY REALLY resented THEN having to stay an extra half an hour or more, UNPAID, to document my care.

(difficult to even know what you are even writing when you are officially hypoglycaemic).

Documentation, according to our governing body, NMC, should be CONTEMPORANEOUS ie > "occuring in the same period of time"

Nurses fail to do this...because there IS NO TIME.

Well, we could omit a bedbath, or a dressing, or a trip to the toilet...

Hi there! This is my first comment here so I just wanted to give a quick shout out and tell you I truly enjoy reading through your posts. Can you suggest any other blogs/websites/forums that go over the same subjects? Thanks a ton!

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.